Orientation (1 point each) | Month | Date | Day of week | Year | Time (within 1 hr) | Orientation score: 5 | Immediate memory (1 point for each correct, total over 3 trials) | | Trial 1 | Trial 2 | Trial 3 | Word 1 | | | | Word 2 | | | | Word 3 | | | | Word 4 | | | | Word 5 | | | | Immediate memory score: 15 | Concentration | Reverse digits (Go to next string length if correct on first trial. Stop if incorrect on both trials. 1 point each for each string length.) | 3-8-2 | 5-1-8 | 2-7-9-3 | 2-1-6-8 | 5-1-8-6-9 | 9-4-1-7-5 | 6-9-7-3-5-1 | 4-2-8-9-3-7 | Months of the year in reverse order (1 point for entire sequence correct) | Dec-Nov-Oct-Sep-Aug-Jul | Jun-May-Apr-Mar-Feb-Jan | Concentration score: 5 | | Delayed recall (Approximately 5 minutes after Immediate memory. 1 point each.) | Word 1 | Word 2 | Word 3 | Word 4 | Word 5 | Delayed recall score: 5 | Summary of total scores: | Orientation | 5 | Immediate memory | 15 | Concentration | 5 | Delayed recall | 5 | Total score | 30 | The following may be performed between the Immediate memory and Delayed recall portions of this assessment when appropriate: | Neurologic screening | Recollection of the injury | Strength | Coordination | Exertional maneuvers | 1 40-yard sprint | 5 sit-ups | 5 push-ups | 5 knee bends | |